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RYC-Camper Medical Info

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					                                         HEALTH HISTORY FORM
                                    GLENDALE CHURCH OF CHRIST
                                        REELFOOT YOUTH CAMP
                                              JUNE 20-25, 2010
                            TO BE COMPLETED BY PARENT OR GUARDIAN
Our camp nurse needs this information to properly identify health care needs. The Health History (two pages)
should be filled out by parents/guardians of minors.
Name: ________________________________________________Birth Date: ________________Age: ______
      Last                     First             MI
Home Address: _____________________________________________________________________________
__________________________________________________________________________________________
Custodial parent/guardian:
Name: __________________________________________________ Home Phone: _____________________
Address: ________________________________________________ Cell Phone: ______________________
Business Address: _______________________________________________ Phone: ____________________
_________________________________________________________________________________________
Second parent/guardian:
Name: __________________________________________________ Home Phone: _____________________
Address: ________________________________________________ Cell Phone: ______________________
Business Address: _______________________________________________ Phone: ____________________
_________________________________________________________________________________________
Emergency Contact: Name ________________________________________ Phone: ____________________

Insurance Information
NOTE: Reelfoot Youth Camp does ot carry any form of accident/illness insurance on campers. Parents are respon-
sible for medical or pharmaceutical expenses incurred at camp. You are obliged to provide the camp with the fol-
lowing information:
Is the participant covered by family medical/hospital insurance? ____ Yes          ____ No
If so, please *Photocopy front and back of health insurance card and prescription card, if separate, and attach to
this form.
If your child needs to be seen by a health care provider other than our camp nurses you will be contacted to secure a refer-
ral from you primary care provider or pick up your child and take him/her to the doctor. If camp staff takes you child to
the doctor, your insurance will be billed and you will be responsible to reimburse us for your copay.
Permission to Provide Necessary Treatment or Emergency Care: I hereby give permission to the camp to provide routine
health care, administer prescribed medications, and seek emergency medical treatment including ordering X-rays or rou-
tine tests. I agree to the release of any records necessary for insurance purposes. I give permission to the camp to arrange
or provide necessary related transportation for my child. In the event I cannot be reached in an emergency, I hereby give
permission to the physician selected by the camp to secure and administer treatment including hospitalization, for the per-
son named above and to communicate with the family physician or orthodontist/dentist if necessary. This completed form
may b e photocopied for trips out of camp. I understand I am responsible for any medical bills not covered by insurance.
Reelfoot Youth Camp and Glendale Church of Christ are released herewith of any liability for any medical ministrations
for any reason. The person herein described has permission to engage in all camp activities except as noted. This health
history is correct and complete as far as I know.
Signature of parent or guardian or adult camper/staff:

_________________________________________________________________________ Date: ____________________

I also understand and agree to abide by any restrictions placed on my participation in camp activities.
Signature of minor or adult camper/staff member: _________________________________________ Date: ___________
                                       TO BE COMPLETED BY PARENT/GUARDIAN
Camper/Staff Member’s Name: __________________________________________________________ Date: _________
Health History Information
Which of the following diseases has the participant had? (Please check)
                ___ Measles              ___ Mumps                 ___ Chicken Pox       ___ German Measles
                                 ___Hepatitis A            ___Hepatitis B          ___ Hepatitis C
Date of last Tetanus: ___________________
General Questions (Explain “yes” answers below)

Has/does the participant:                                  Yes    No    Has/does the participant:                           Yes   No
1. Had any recent injury, illness or infectious disease?                17. ever had back problems?
2. Have a chronic or recurring illness/condition?                       18. If female, have an abnormal menstrual his-
                                                                        tory?
3. Ever been hospitalized?                                              19. Ever sought professional help for emotional
                                                                        difficulties
4. Ever had surgery?                                                    20. Had mononucleosis in the past 12 months
5. Have frequent headaches?                                             21. Ever passed out during or after exercise?
6. Ever had a head injury?                                              22. Ever been dizzy during or after exercise?
7. Ever been knocked unconscious?                                       23. Ever had chest pain during or after exercise?
8. Wear glasses, contacts or protective eye wear?                       24. Ever had an eating disorder?
9. Ever had frequent ear infections?                                    25. Ever required hospitalization for trauma?
10. Ever had problems with joints, i.e., knees, ankles?                 26. Ever had high blood pressure
11. Have an orthodontic appliance being brought to                      27. Ever been diagnosed with a heart murmur?
camp?
12. Have a history of bed-wetting?                                      28. Ever had seizures/epilepsy
13. Have problems sleepwalking?                                         29. Have diabetes?
14. Have any skin problems, i.e., itching, rash, acne?                  30. Have asthma?
15. Had problems with diarrhea?                                         31. Have known food allergies?
16. Had problems with constipation                                      32. have known drug allergies?
Please explain any “yes” answers, noting the number of the question: ___________________________________________________
___________________________________________________________________________________________________________


                                                Medications to be taken at Camp
Please list ALL medications being brought to camp. Bring enough medication to last the entire time at camp. Medications MUST be
in the original packaging/bottle that identifies the name of the medication, dosage, frequency of administration. Parents must include
a note for all non-prescription meds.
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
This camper takes NO medication on a routine basis (please check if appropriate) _____
Are there any physical, emotional, or mental concerns about which the cabin counselor or activity instructors should be informed?
If yes, please explain: ________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Name of family physician _______________________________________________________________ Phone: _______________
Address _____________________________________________________________________________ Phone ________________
Name of family dentist/orthodontist _______________________________________________________ Phone ________________
Address ___________________________________________________________________________________________________
    Any changes to this form should be provided to camp health personnel in writing when the participant arrives at camp.

				
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